1. Technical Field of the Invention
The present invention is generally related to medical claims processing, and more specifically, but not by way of limitation, to a method of and system for rules-based population of a knowledge base used for medical claims processing.
2. Description of Related Art
The healthcare industry has become very large from the standpoint of financial transactions. Healthcare providers (“providers”), such as hospitals, physicians, and professional service providers (e.g., laboratories, pharmacies), have expanded treatment and services as medicine has become more diverse in treating people for many more ailments than in the past. One reason for the expanded treatment and services includes advancements in research and development of technology to aid physicians in diagnosing and treating patients.
Accordingly, the healthcare insurance industry has grown to assist patients in paying for healthcare expenses. In providing for payment of services, healthcare insurance companies and other payment organizations (e.g., Medicare, Medicaid, etc.) (“payers”) have established medical services and procedures to be covered for the treatment of patients. The providers and other organizations (e.g., industry standards groups and government regulators) have developed a variety of protocols to submit payment requests or medical insurance claims (“claims”) to the payers for payment or co-payment of treatment and services rendered by the providers.
The protocols that have been developed by the payers and other organizations were developed in an effort to form standards by which payers recognize treatment procedures and services performed. The protocols enable the payers to more easily determine if treatment procedures and services are covered by the insurance policies of patients. As the industry developed, a number of different protocols developed in the way of claim forms, including UB-92 (formerly UB-82), which is utilized by institutional providers (e.g., hospitals), HCFA 1500, which is utilized by professional providers (e.g., physicians), and institutional and professional 837, the newest standard mandated by HIPAA. The claim forms traditionally were in the form of paper. However, the claim forms have evolved with technology and many are now prepared on a computer in an electronic format. While most providers utilize computers to prepare the electronic claim forms, small and rural providers continue to utilize paper claim forms.
Whether the provider utilizes paper or electronic claim forms, the various codes that identify medical diagnosis and treatment that have been generated by healthcare industry standards groups (e.g., National Uniform Billing Committee (NUBC), State Uniform Billing Committee (SUBC), government regulators, the AMA, CMS, payers, etc.), are used in filling out claim forms for submission to payers. By utilizing standardized codes, providers and payers may communicate in a uniform manner. There are approximately 20 different code sets containing nearly 60,000 unique codes that have been developed for providers to utilize based on the specific field of medicine, service, treatment, etc., that is provided to the patient. For example, the International Classification of Disease 9th revision codes, generally known as ICD-9 codes, are utilized to describe diagnoses and the treatment of medical conditions afflicting various body parts (e.g., head, arms, legs, etc.). Other types of codes include Common Procedure Terminology (CPT) codes, which are used for physician codes; Diagnosis Related Group (DRG), which are used for in-patient procedures; and Healthcare Procedure Coding Systems (HCPCS), which are used to report outpatient procedures, drugs, durable medical equipment and outpatient services. As understood in the art, the codes generally are updated annually and new types of codes are created as medical procedures and specialties are formed.
While the code sets have been established to enable the healthcare and insurance industries to use common codes, there are many reasons why reporting problems result in a medical procedure or service not always being easily classified with a particular code or properly reported. A provider may perform a procedure and write or dictate a treatment analysis to be submitted for insurance reimbursement. One claim coder (i.e., individual who interprets the treatment analysis and assigns the proper code into the claim form) may interpret the treatment analysis differently from a different claim coder. And, based on the correctness of, and compliance to, claim submission rules of the claim codes submitted, the payer may or may not approve the procedure or treatment for reimbursement.
FIG. 1A is a diagram of a sample UB-92 claim form. The claim form includes 85 identified fields for entry of information and/or codes. Various information may be entered into the associated fields. For example, field 1 is used for entry of the provider name, address, and telephone number, as required. Field 3 is used for entry of the patient control number, which is the account number for the patient. As indicated, no special characters (e.g., *, @, -, #, etc.) are allowed. Field 4 indicates the type of bill and is a three-digit code, where the first digit indicates type of provider (e.g., hospital, skilled nursing, home health, etc.), the second digit indicates the type of care (e.g., inpatient, outpatient, specialized services, etc.), and the third digit indicates the type of claim (e.g., non-payment/zero claim, admit through discharge claim, interim-1st claim, etc.). Fields 67-81 are used to enter ICD-9 codes for diagnosis and procedure identification. As indicated, determining the proper codes to insert is often complex and difficult, especially codes relating to the diagnosis and procedure information of the ICD-9 codes. In fact, comprehensive educational courses are provided to medical assistants to teach how the forms are to be properly filled out.
Entry of the UB-92 claim form may be a challenging task due to the complexity of information necessary and to the complexity of the medical codes and insurance information that must be determined and entered. While one may become an expert at entry of the claim form, because each payer has different rules for authorizing payment based on the information submitted on the claim form and because each provider has different methods or procedures for determining the information to be entered into the claim form, the claim submission and reimbursement process often becomes a financial burden for both the provider and payer, delaying payments and increasing healthcare administrative costs.
As well understood in the art, there are large numbers of providers and payers. While there are an estimated 3000(+) major providers and payers, there are several thousands of physicians, all of whom submit claim forms to the thousands of payers. Because patients of a single provider facility may have insurance with many tens or hundreds of payers, the providers are overburdened and practically incapable of maintaining knowledge as to the rules and requirements, addressees, contacts, etc., for each payer. One quickly understands the magnitude of the coordination of communications needed between the providers and payers.
To assist both the provider and payer with the coordination of claim submission, an industry of clearinghouses has developed. FIG. 1B is a diagram that illustrates an exemplary business model of providers 102a-102d (collectively 102) for submitting claim forms 103 to payers 104a-104d (collectively 104) via clearinghouses 106a-106c (collectively 106). The claim form 103 may be submitted on paper or electronically via data packets 108 across a communication system (See FIG. 4). As can be seen in FIG. 1A, the number of communication links between the providers 102 and payers 104 is substantially reduced by the inclusion of the clearinghouses 106.
The clearinghouses 106 perform, at least in part, distribution duties similar to a postal distribution center for the providers of the claim forms 103 in either paper or electronic formats. The clearinghouses 106 perform, at least in part, communication of status (e.g., acceptance, rejection, etc.) of the submitted claims from the payers 104 to the providers 102. The process by which the claims are accepted or rejected by the payers 104 is generally known as the adjudication process.
FIG. 2 is a diagram that illustrates an exemplary process time line 200 describing general operations for processing a medical claim by the parties of FIG. 1B. The processing may include preparing, submitting, distributing, adjudicating, and remitting on the claim for the providers 102, clearinghouses 106, and payers 104. As understood in the art, the process starts at step 202 as the claim form 103 is filled out with patient information, such as name, address, phone number, religion, etc., at a pre-admit phase of a patient being processed to see a provider. At step 204, an admission and eligibility phase is performed by the provider determining eligibility for services of a patient and admitting the patient to be treated. The process of admitting the patient may be determined based on, at least in part, the patient having valid insurance and/or credit. The admission/eligibility phase at step 204 may further include the process of provider 102 treating and/or diagnosing the patient.
At step 206, the patient is discharged by the provider 102. The provider 102 may thereupon update a patient chart for the patient with treatment and diagnosis information as understood in the art. The treatment and diagnosis information may be transposed onto the claim form 103 by determining the appropriate codes (e.g., ICD-9 codes) to enter into the correct field(s) (e.g., field 67) of the claim form 103 at step 208. Once the claim form 103 is completed and ready for submission to a payer 104, a “bill drop” or communication of the claim form 103 may be made from the provider 102 electronically or via mail at step 210. In general, the bill drop at step 210 is performed in a batch process to the clearinghouse 106 due to the fact that computer systems of the providers 102 and payers 104 do not have direct communication because the computer systems and software do not share compatible architectures.
Some of the reasons for the computer systems of the providers 102 and payers 104 not having compatible architectures include: (1) the healthcare industry having traditionally performed paper processing transactions, (2) the computer and software systems of the providers 102 and payers 104 never having been developed to communicate with one another, (3) the codes developed for the providers 102 not necessarily having been communicated to and adopted by the payers 104, (4) the clearinghouses 106 having been established to manage and process claims, thereby not having an incentive to adopt a direct, real-time payment system between the providers and payers, (5) the payers having limited incentive to expedite payment as delay in payment increases interest revenue for the payers, (6) the number of people, organizations and government entities defining codes adding layers of complexity to the process, and (7) technology not having been fully adopted by the healthcare industry. For example, there are very few direct connections between trading partners (i.e., specific provider 102 and payer 104).
Software developers and information technology companies that the providers 102 and payers 104 have utilized to develop systems and software to manage the claims processing have generally been devoted to either the provider 102 or payer 104, so that the concerns of the other side essentially have been unincorporated in the development process. In other words, the business model for the systems have focused on either the payer 104 or provider 102 side in terms of collecting revenue. On the provider side, the systems are established to conform to the needs of the general population of payers 104 (e.g., to form submission compliance with as many payers 104 as possible), which typically causes the systems to be less compatible with any specific payer 104. On the payer side, the systems are established to conform to the needs of the specific payer systems without regard to the capabilities of the providers' systems (e.g., to receive form submission from as many providers 102 as possible), which typically causes the systems to be less compatible with any specific provider 102.
While the incompatibility of the systems of the providers 102 and payers 104, and lack of desire and motivation of the payers 104 have held back progress in improving the technology for the healthcare industry to more efficiently and effectively process claims, the major problems that the industry has to overcome include, but are not limited to, the (i) dynamic environment of rapidly changing codes, (ii) conflicting reporting requirements, and (iii) contradictory claim filing guidance. These problems and turmoil have resulted in a complete industry being created to focus on interpreting the changes in codes and reporting guidance and creating software programs to evaluate the contents of the claim forms 103 and assess the validity of the claim forms 103 before being sent to the payer 104 for adjudication and settlement. This industry, which includes clearinghouses 106, receives change notifications and error reports in many different forms. In many cases, an originator of the change announces how the change should be handled by payers and fiscal intermediaries. These change handling instructions are referred to as “edits” as understood in the healthcare industry or various other industries.
Continuing with FIG. 2, the process of applying edits to submitted claim forms is performed at step 212. This process is performed by the clearinghouse 106 for each of the claims submitted in a batch, which may include large numbers (up to 500 or more) of claims. Edits may come in many forms, including being (i) tucked into the body of a government released transmittal, (ii) listed in a spreadsheet or table containing hundreds or thousands of edits that have been created by both providers 102 and payers 104, and (iii) contained in the text of specification documents such as, for example, the X12 Institutional 837. In many cases, edits are created by provider organizations in order to overcome a shortfall in a legacy accounting system that cannot be modified to accommodate new changes. Regardless of the source for the edits, the edits are almost always provided in free form English language text. Because the edit text is generated by different individuals, in different locations, at different times, often using different sentence structures, and because of the nature of the edit generation process, the task of analyzing, cataloging, and managing edits has become a time and labor-intensive activity. One example of the complexity of managing edits is a healthcare management company having 100 provider institutions located in ten different states submitting medical insurance claims to Medicare, ten different Medicaid payers, an undetermined number of commercial payers, and Civilian Health and Management Program Uniformed Service (CHAMPUS), which recently became Tricare, for providing medical insurance to military dependents and retired military personnel, thereby resulting in the healthcare management company having 10,000 or more edits to manage.
The term “edits” historically was used to describe the process of correcting information in a data file. While the edits still refer to correcting information, the term “edits” in the healthcare industry for insurance claims provides for a directive to correct information that is incorrect or to reject claims that do not comply with business rules established by a payer. In other words, the edits may be considered statements of situations that cause an error to occur to hinder payment or processing of final adjudication of a particular insurance claim. The business rules of payer 104, which may be established arbitrarily or based on the policies of the payer 104, for example, may be established and modified on an annual basis or more frequently. For example, one business rule may be as simple as requiring the last name to be entered with all capital letters. Another business rule may indicate that a certain procedure is to be denied reimbursement if a certain diagnosis not requiring the procedure to be performed is reached. Yet another business rule may require a certain identifier in a field if an intern assists in a medical procedure. And, if any of these business rules are violated, an edit is generated and applied to the insurance claim form 103 to notify the provider 102 that a correction is needed per the instructions of the edit.
An example of an edit includes the following: “Move UPIN from 82AA to 82BA,” where UPIN is an abbreviation for universal provider identification number and AA and BA are field identifiers in the form locator referring to an attending physician on a UB-92 claim form 103. As understood in the art, the word “move” alternatively may be written as “copy,” “change,” include,” or other synonym in an edit. The choice of words for an edit is arbitrary as there are no particular standard terms to be used for edits for the individuals who generate the edits. And, because of the multitude of different, yet related terms, the edits associated with the business rules may mean the same thing or be substantially semantically similar and unnecessarily increase the overall number of edits to which the providers must adhere.
The end goal for the providers 102 is to expedite final adjudication of medical claims by minimizing rejection of the medical claims by the payer 104 due to errors entered on the claim forms 103. To minimize the errors entered on the claims form 103, an understanding of the edits is desirable as the edits offer a roadmap for mistakes that may be made in view of the business rules and codes utilized to adequately and correctly complete the claim forms 103 for claim validation. Claim validation occurs when at least the following items are satisfied: (i) the claim form 103 is complete in the eyes of the payer 104, (ii) the data are properly formatted in the proper location on the claim form 103, and (iii) the data accurately reflects medical services provided and meets service constraints, which are generally embodied in the edits. However, because of the large volume of edits and frequency of edit modifications, creation of a complete understanding and knowledge base of the tens of thousands of edits is substantially impossible for an individual attempting to design a system to expedite medical claims processing.
After the process of applying edits to a claim form at step 212, if there are no edits applied to the claim form 103 because no errors were detected, then the claim form 103 is communicated to the payer 104 in a format that the payer 104 requires. Otherwise, if errors were detected on the submitted claim form 103, then the claim form 103 and associated edits 215 are communicated back to the provider 102 for correction to the claim form 103.
At step 216, the payer 104 receives the claim form 103. A receipt of receiving the claim form 103 may be communicated back to the provider 102 via the clearinghouse 106 for notification purposes. At step 218, the payer 104 adjudicates on approving the claim for payment purposes. The adjudication is based on rules or policies that the payer 104 may have for the health insurance plan of the patient. Generally, the edits include enough of the policies so that the claims are approved by the payer 104, but is not always the case.
At step 220, a status including the results of the adjudication process of step 218 may be communicated via the clearinghouse 106 back to the provider 102. If the claim was rejected, the provider 102 may be allowed to cure the defect. Additionally and/or alternatively, the provider 102 or patient may appeal the rejection at this stage without having to resubmit another or amended claim form 103. If the claim was approved, then payment 223 of the claim may be resubmitted to the provider 102, either directly or indirectly. At step 224, the provider 102 receives the payment 223 and applies it to collections at step 226. At this point, the claim is considered closed as payment by the payer 104 has been tendered.